You will not be responsible for the costs of “surprise bills” for out-of-network services, other than any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.
What is a “surprise bill”? What are some examples?
Not all out-of-network services are surprise bills. A surprise bill is a bill for covered non-emergency health care services rendered on or after April 1, 2015, where one of the following situations applies:
- You receive covered health services from an out-of-network physician at an in-network hospital or ambulatory surgical center, in any one of the following circumstances:
- An in-network physician is unavailable
Example: You are not told that the scheduled in-network surgeon stepped out of the procedure and an out-of-network surgeon stepped in.
- An out-of-network physician delivers services and you didn’t know that physician was out of network
Example: You receive covered health services at an in-network ambulatory surgical center, and during that visit an out-of-network anesthesiologist provides services to you, without your knowing of that doctor’s out-of-network status.
- You need unexpected medical services while receiving other services
Example: Unexpected medical needs arise and an out-of-network surgeon is brought in to perform the unexpected services.
If a network provider was available and you elected to receive services from a non-participating provider anyway, then it is not a surprise bill.
- An in-network physician is unavailable
- An in-network physician referred you to an out-of-network provider, and you received covered health services without written consent acknowledging that you:
- Knew that you are being referred to an out-of-network provider, and
- Knew that getting services from that out-of-network provider could result in costs not covered by Carelon Behavioral Health
A referral to a non-participating provider occurs when:
- the health care services are performed by a non-participating health care provider in the participating physician’s office or practice during the course of the same visit;
- the participating physician sends a specimen taken from the patient in the physician’s office to a non-participating laboratory or pathologist; or
- for any other health care services when referrals are required under the member’s contract (i.e., a gatekeeper such as HMO or POS)
Example 1: You receive covered health services in an in-network physician’s office, and during that visit an out-of-network provider in the same office or practice provides services to you, without your written consent that you knew of that provider’s out-of-network status and that you may incur non-covered costs.
Example 2: An in-network physician sends your lab specimen taken during an in-network office visit to an out-of-network lab or pathologist, without your written consent that you knew of that provider’s out-of-network status and that you may incur non-covered costs.
- An individual covered by a self funded plan receives health services from a provider at a hospital or ambulatory surgical center, where the health care provider did not give the individual certain required information.
How does Carelon Behavioral Health process claims for non-emergency surprise bills?
If Carelon Behavioral Health gets a claim for out-of-network services that isn’t submitted with a completed surprise bill Assignment of Benefits Form, Carelon Behavioral Health will process the claim as usual – that is, we will deny the claim if you only have in-network coverage, e.g., HMO or EPO, or, if your plan includes out-of-network benefits (usually called a PPO or POS plan), we will process the claim according to the terms and conditions that normally apply to out-of-network services — which usually involve higher cost-sharing and higher out-of-pocket costs than for covered in-network services. We will then send you a notice — either within, or together with, your Explanation of Benefits — explaining that the claim could be a surprise bill, and that you should contact Carelon Behavioral Health or refer to this web page for instructions on what to do next.
If Carelon Behavioral Health gets a claim for out-of-network services along with a completed surprise bill Assignment of Benefits Form, or a claim that we determine is a surprise bill without also receiving a surprise bill Assignment of Benefits Form, we will send you a notice explaining that:
- Your out-of-pocket costs for the services related to the surprise bill won’t be any higher than if you’d received them from an in-network provider,
- Your cost-sharing for the services may increase if an IDRE (independent dispute resolution entity) decides that Carelon Behavioral Health must pay an additional amount(s) to the provider for the services, and
- You should contact Carelon Behavioral Health if the out-of-network provider bills you for the out-of-network service.
What if Carelon Behavioral Health doesn’t know a claim should be handled as a surprise bill?
We will process the claim as described above and provide notice that it may be a surprise bill.
If you feel Carelon Behavioral Health should have processed a claim as a surprise bill, you should complete a surprise bill Assignment of Benefits Form and submit it to Carelon Behavioral Health You also have the option to dispute our decision on the claim by filing a grievance.
For the address and other contact options for submitting forms, and for instructions on filing a grievance, see the section on this page “Disputing Claims for Out-of-Network Emergency Services or Surprise Bills.”